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Saturday, March 07, 2009

Buddhism, Psychotherapy, and Medications

The current issue of Buddhadharma has a fantastic article called Medicate or Meditate? that looks at Buddhism, psychotherapy, and the use of medications - all in the context of how this may or may not impact our practice and our lives. The authors are physicians and long-term meditators: Roger Walsh, Robin Bitner, Bruce Victor, and Lorena Hillman.

Here is a cool piece from the article, from the section Psychotherapy and Meditation:

When Buddhism first came to the West, many teachers and practitioners initially dismissed psychotherapy as superficial, unnecessary, and possibly counterproductive. As time went on, more and more students faced crises or simply felt their spiritual practice was not dealing with deeper problems that were hindering their development. Psychotherapy’s relationship to spiritual practice started to undergo a reevaluation, and the two disciplines began to intermingle a bit more. Among the first to bridge the divide between therapy and spiritual practice was Jack Kornfield, who is both a meditation teacher and psychologist. In 1993, he wrote an article called “Even the Best Meditators Have Old Wounds to Heal: Combining Meditation and Psychotherapy,” which was published in the book Paths Beyond Ego: The Transpersonal Vision. In it he argued:

For most people, meditation practice doesn’t “do it all.” At best, it’s one important piece of a complex path of opening and awakening….There are many areas of growth (grief and other unfinished business, communication and maturing of relationships, sexuality and intimacy, career and work issues, certain fears and phobias, early wounds, and more) where good Western therapy is on the whole much quicker and more successful than meditation….Does this mean we should trade meditation for psychotherapy? Not at all….What is required is the courage to face the totality of what arises. Only then can we find the deep healing we seek—for ourselves and for our planet.

Controversial in their time, Kornfield’s ideas have now gained wide acceptance. In fact, meditation and psychotherapy are being integrated in many different contexts, as therapy clients and patients are offered meditation and meditators are offered therapy. Research has convinced therapists of the value of meditation for a host of psychological and psychosomatic difficulties. In fact, many therapists and meditation teachers now agree that meditation and psychotherapy can be mutually facilitating. Meditators seem to progress more quickly in therapy, while psychotherapy can improve the effectiveness of their meditation.

In addition, combination therapies that integrate meditation and psychotherapy are proliferating, and often prove more effective than either application alone. The original inspiration was Jon Kabat-Zinn’s widely used “mindfulness-based stress reduction” (MBSR). Originally designed to treat chronic pain, MBSR has since proved helpful with a diverse array of psychological and psychosomatic difficulties. Examples of disorders that have responded well to MBSR range from anxiety, aggression, stress, and eating disorders on the psychological side to asthma, angina, and high blood pressure on the somatic side.

Several recent combinations merge Buddhist mindfulness with specific psychotherapies. These include, for example, “mindfulness-based cognitive therapy” for depression, “mindfulness-based sleep management” for insomnia, and “mindfulness-based relationship therapy” for enhancing relationships. Research affirms the effectiveness of each of these approaches. More broad-based combination treatments—such as transpersonal and integral therapies—incorporate multiple psychological, spiritual, and somatic strategies. In short, the integration of contemplative and conventional therapies is proceeding rapidly, and the results are promising.

Combining meditation and psychotherapy makes sense if we appreciate how they work in complementary ways. For the most part, meditation focuses primarily on developing capacities such as concentration and awareness, whereas psychotherapy focuses primarily on changing the objects of awareness, such as emotions and beliefs. Of course, there are also significant overlaps, but this complementarity suggests why combining both approaches can be very helpful. Meditative qualities can facilitate psychotherapeutic healing of painful patterns, while the psychotherapeutic healing of these painful patterns can reduce their disruption of spiritual practice.

What are the practical implications of this conjunction of psychotherapy and spiritual practice? It seems clear that the question of whether meditation and psychotherapy can enhance one another has been decided: many people benefit from combining them, and this has been observed by clinicians and demonstrated by research. When old traumas, pains, and patterns recycle endlessly, or make spiritual practice seem overwhelming and hopeless, the best answer may not be simply the classic one of more practice. Instead, psychotherapy may be called for.

While many Buddhists, especially those from traditional Buddhist backgrounds (Tibetan, Bhutanese, Japanese) tend to argue that all you need is Buddhist practice, and that Western psychology is not a necessary part of the path, I disagree completely. Having done both, and having done them together, the synergy is amazing.

I'm glad to see Buddhadharma publishing what is described in the article as a pragmatist approach to this issue - there is too much dogma on either side most times. Taking the middle way through this tough issue is the best path as far as I can tell.

In addition to the issue of combining therapy and practice, the authors also tackle the stickier topic of using medications for Buddhists.

Spiritual purists argue that if mental suffering is fundamentally spiritual and karmic, spiritual practice alone is appropriate to treat it. A standard response to difficulties is therefore “more practice.” Moreover, they are concerned that medication may dull or derail spiritual practice. They worry that if suffering is merely dissolved with a pill, the motivation to practice may dissolve with it. They also worry that medications may reduce or distort awareness, and thereby make practice more difficult. In this view, medications such as antidepressant or antianxiety agents can be novel forms of the “mind-clouding intoxicants” prohibited by the lay precepts to which many Buddhist practitioners adhere. Therefore, taking these modern pharmacological agents is tantamount to violating this precept. Another worry is that potentially valuable spiritual challenges such as the classic “dark night of the soul” may be misdiagnosed as psychopathology, and then be suppressed with drugs rather than explored and mined.

By contrast, pragmatists hold that spiritual practice alone is simply insufficient, or at least not optimal, for healing all mental suffering. While not denying the validity of some purist concerns, pragmatists argue that certain problems and pathologies respond best to other therapies, and one of these therapies can be medication. Stan and Christina Grof—who have written extensively about spiritual emergencies and founded the Spiritual Emergence Network to offer support to people who find themselves in such emergencies—encourage this pragmatic perspective. They certainly agree that some spiritual emergencies are best treated not with medical suppression, but with time-honored spiritual and psychological principles. These principles include providing a supportive relationship with a spiritual guide, reframing (where appropriate) the emergency as a spiritual process and opportunity, and setting positive expectations. However, they also recognize that some emergencies are so overwhelming that they require medical intervention.

As for the idea that there is something inherently unspiritual about taking drugs to modify neurotransmitters such as serotonin, we might consider how John Tarrant Roshi, who is also a Ph.D. psychologist, demystifies the brain’s chemistry. “What is serotonin?” he asks. “It, too, is a piece of the original light. For some people it comes in the form of serotonin; for others in the form of a smile. There is more than one way to move neurotransmitters around—meditation can do it; having someone hug you does it, too.”

The purist-pragmatist debate is curiously reminiscent of one that rocked psychiatry decades ago. At that time, the psychiatric world was ruled by psychoanalysts who believed that virtually all psychological problems and pathologies could be traced to earlier psychological causes. They threw up their hands in horror when antidepressants and antipsychotic medications first appeared, claiming that the drugs merely relieved surface symptoms, while leaving the deeper causes untouched. Eventually they changed their minds as pharmacological successes multiplied, and especially when some long-analyzed but little-helped patients responded well to antidepressants, and subsequently sued their psychoanalysts for having withheld medication. It’s not that psychoanalysis is useless, but rather that by itself, it may be insufficient to treat severe psychological disorders. Likewise, meditation and spiritual practice may also be insufficient by themselves to address severe psychological difficulties.

This is of special interest to me. I do not suffer from depression, at least not today, but I do suffer from generalized anxiety disorder (GAD) and social anxiety disorder (SAD).

When I was young and dumb, I tried to self-medicate with weed. Then, when that got me into trouble, I switched to alcohol. That didn't work out so well, so I quit drinking and tried kava and St. John's Wort. Those had some benefit, especially since I was also meditating regularly at that point (this was around the time I had started reading Tricycle and Shambhala Sun). The combination gave me some relief, but in social situations I was still looking for a door, sweating, and feeling like I was about to be jumped by a tiger.

I stuck with the meditation. But it didn't help. I got myself into therapy, but it didn't solve the problem, either. Finally, I did some research online and decided that paxil was a viable option. About two years ago I started taking paxil at 20 mg a day, then 30, and now 40 mg daily. My social anxiety is markedly better, though not gone. The generalized anxiety is mostly a bad memory.

More importantly, I didn't suffer the 15-25 lb weight gain many people report - in fact, I lost weight. I did not suffer a loss in sexual interest or performance, as so many others do. And I haven't had any of the other side effects. I'm NOT telling anyone that they should try this approach - I'm just saying it worked for me.

Here is a key quote from the article:

Again, this is not to say that spiritual practice or psychotherapy won’t help, but rather that, by themselves, they may be insufficient. Even very long-term practice may be insufficient. In fact, we have seen and consulted with not only practitioners, but also several teachers whose long, dedicated practice was simply not enough to fully override genetic forces and major traumas, and who benefited from medication. Optimal healing may require multiple therapies, one of which is pharmacotherapy.

In general, I think we are all concerned with optimal healing - what is best overall. For some of us, that includes medication. I am happier, more effective in my job, and healthier than I was before trying medication. Practice is important, therapy helped, but it wasn't until I added the chemical approach that it all came together.

Books on Mindfulness, Buddhism, and Psychotherapy

In recent years, the number of books - especially neuroscience books - looking at the intersection of mindfulness and psychotherapy has sky-rocketed. This is both good and bad. Good in that Buddhist practices are being more widely disseminated, and bad that a lot of the subjective element is being dismissed in favor of how these practices alter the brain.

Mindfulness-based cognitive therapy (MBCT) is a method of psychotherapy which blends features of cognitive therapy with mindfulness techniques. MBCT involves accepting thoughts and feelings without judgement rather than trying to push them out of consciousness, with a goal of correcting cognitive distortions. MBCT's main technique is based on mindfulness-based stress reduction, which was adapted for use with major depressive disorder. Relaxation and happiness are not the aims of MBCT, but rather a "freedom from the tendency to get drawn into automatic reactions to thoughts, feelings, and events".[1] MBCT programs usually consist of eight-weekly two hour classes with weekly assignments to be done outside of session. The aim of the program is to enhance awareness so clients are able to respond to things instead of react to them.[2]

With that in mind, here are a few of the most recent books (links take you to the title at Amazon) on combining mindfulness and psychotherapy.